systems

Article

Dynamic Response Systems of Healthcare MaskProduction to COVID-19: A Case Study of Korea

EunSu Lee 1,* , Yi-Yu Chen 1, Melanie McDonald 1 and Erin O’Neill 2

1 Management Department, New Jersey City University, Jersey City, NJ 07311, USA; ychen@njcu.edu (Y.-Y.C.);mmcdonald@njcu.edu (M.M.)

2 Health Sciences Department, New Jersey City University, Jersey City, NJ 07305, USA; eoneill@njcu.edu* Correspondence: elee3@njcu.edu; Tel.: +1-701-205-1525

Received: 21 April 2020; Accepted: 25 May 2020; Published: 29 May 2020�����������������

Abstract: Korea initiated a new experiment, called a dynamic response system for open democraticsocieties as a principle to respond to the novel coronavirus (COVID-19). The global pandemic ofCOVID-19 led to a surge in demand for healthcare medical masks and respirators, and strained theglobal supply chain of mask production and distribution systems. This study provides a systemicview of critical personal protective equipment for both healthcare staff and the public to stop thespread of COVID-19. This study investigates the dynamic response system of healthcare maskproduction to the coronavirus and discusses lessons learned in view of systems thinking. The studyshows that it is critical to developing a quick and dynamic response system to the evolving marketconditions with flexible and agile operations. Visibility with transparency with information sharingwith the public is also critical under global pandemic. Due to the shortage of mask supply, smartconsumption is required along with collaboration with public and private sectors, as well as globalorganizations. Democratic leadership and a well-prepared strategic plan for long-term period areessential to the open society to prepare the global pandemic in the future. This study serves as abenchmark for dynamic and timely responses to the global pandemic.

Keywords: dynamic response systems; COVID-19; pandemic; production capacity; demandmanagement; systems thinking; healthcare masks; medical masks; respirators

1. Introduction

The first novel coronavirus (COVID-19) case was reported in South Korea on 20 January 2020.The Korea Center for Disease Control and Prevention (KCDC) was ready to fight the new pandemicwith lessons learned from the painful experience of failing to respond to the 2015 MERS (MiddleEast Respiratory Syndrome) outbreak. The authority promptly convened an emergency committeemeeting to discuss dynamic and timely responses on 22 January 2020 [1]. Korea initiated a newexperiment, called a dynamic response system for open democratic societies as a principle to respondto the coronavirus, COVID-19 [2]. Rather than rigid ways of closing the border or deterring the flow ofpeople and products crossing the borders around the world, the government began to build continuoussensing and response capabilities in addition to the contingency plans for responding to pandemics inthe complex and uncertain crisis [3].

The KCDC has been trying to persuade and encourage people to wash their hands frequentlyfor hand hygiene, to wear masks, and to practice social distancing in order to sustain global andlocal social and economic flows in an open society. In general, three common pathways of virusesare reported—droplets, aerosol, and fomites [4,5]. Although people practice social distancing, acampaign considering the cases of direct transmission through droplets promotes wearing a high-gradehealthcare mask, such as a KF94 mask, to prevent aerosol infection in certain situations (as seen

Systems 2020, 8, 18; doi:10.3390/systems8020018 www.mdpi.com/journal/systems

Systems 2020, 8, 18 2 of 17

in China, Hong Kong, Korea, Singapore, and Taiwan). By doing so, people can continue to retaineconomic and social activities.

In addition, COVID-19 may be active for about 5 to 10 days without any symptoms [6], and canspread to others during this non-symptomatic period. The World Health Organization (WHO) andthe U.S. Centers for Disease Control and Prevention (CDC) did not recommend that the public wearmedical masks or respirators, except for infected patients and medical personnel [7,8]. However, theWHO and CDC recently started to recommend that the general public wear cloth masks to lower thelikelihood of transmission, particularly as infected persons may be asymptomatic. Moreover, eventhough a person has no symptoms, wearing a mask is necessary to protect others from infection incase the person is infected without presenting any symptoms. Thus, the KCDC recommends wearinga healthcare mask if people with underlying medical condition contact others within 2 m of poorlyventilated space. The U.S. CDC also have changed their guidelines for the public, advising themto wear cloth masks in public settings, such as grocery stores and pharmacies, where significantcommunity-based transmission is possible [9,10].

This has led to a surge in demand for healthcare, medical, and respiratory masks. Sudden spikesin demand have not only constrained production, supply of raw materials, and distribution systemsfrom meeting demand, but also put a strain on the social systems. In general, the market size of masksis estimated by subtracting export from the sum of domestic production and import.

Recently, as the inhalation of fine dust has become a frequent cause of serious public healthproblems, Korea’s mask market has grown rapidly, and thus, its imports and production of masksincreased exponentially—until the outbreak of the novel coronavirus in 2020. Exports have decreased,as domestic demand increases (Figure 1). While the capacity of domestic mask production in 2019reached up to average three million masks per day, it was not enough for the market to respond to thecoronavirus outbreak.

Systems 2020, 8, x FOR PEER REVIEW 2 of 18

in China, Hong Kong, Korea, Singapore, and Taiwan). By doing so, people can continue to retain economic and social activities.

In addition, COVID-19 may be active for about 5 to 10 days without any symptoms [6], and can spread to others during this non-symptomatic period. The World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) did not recommend that the public wear medical masks or respirators, except for infected patients and medical personnel [7,8]. However, the WHO and CDC recently started to recommend that the general public wear cloth masks to lower the likelihood of transmission, particularly as infected persons may be asymptomatic. Moreover, even though a person has no symptoms, wearing a mask is necessary to protect others from infection in case the person is infected without presenting any symptoms. Thus, the KCDC recommends wearing a healthcare mask if people with underlying medical condition contact others within 2 m of poorly ventilated space. The U.S. CDC also have changed their guidelines for the public, advising them to wear cloth masks in public settings, such as grocery stores and pharmacies, where significant community-based transmission is possible [9,10].

This has led to a surge in demand for healthcare, medical, and respiratory masks. Sudden spikes in demand have not only constrained production, supply of raw materials, and distribution systems from meeting demand, but also put a strain on the social systems. In general, the market size of masks is estimated by subtracting export from the sum of domestic production and import.

Recently, as the inhalation of fine dust has become a frequent cause of serious public health problems, Korea’s mask market has grown rapidly, and thus, its imports and production of masks increased exponentially—until the outbreak of the novel coronavirus in 2020. Exports have decreased, as domestic demand increases (Figure 1). While the capacity of domestic mask production in 2019 reached up to average three million masks per day, it was not enough for the market to respond to the coronavirus outbreak.

Figure 1. Import and export data of the category of mask products (HS Code: 6307.90-9000) from 2005 to 2019 [11]. Korean won (KW) was converted into the U.S. Dollar based on the average exchange rate from Reference [12]. Production in 2019 was estimated by 3 million masks × 311 days per year × 390 KW per mask.

The COVID-19 global outbreak is an emergency, which in turn produces a range of consequences that require urgent and coordinated action to produce personal protection equipment (PPE), including face masks [13]. Due to the outbreak, the resources and capacity of production and

Figure 1. Import and export data of the category of mask products (HS Code: 6307.90-9000) from 2005to 2019 [11]. Korean won (KW) was converted into the U.S. Dollar based on the average exchange ratefrom Reference [12]. Production in 2019 was estimated by 3 million masks × 311 days per year × 390 KWper mask.

The COVID-19 global outbreak is an emergency, which in turn produces a range of consequencesthat require urgent and coordinated action to produce personal protection equipment (PPE), including

Systems 2020, 8, 18 3 of 17

face masks [13]. Due to the outbreak, the resources and capacity of production and distributionsystems are constrained. To continue the systems operational and sustainable, system resilience playsan important role in the accomplishment of the system’s goals in the face of the global pandemicand limited resources [14]. The resilience system characterizes as adaptive capacity addresses asystems’ capability to dynamically extend capacity on the surge of mask demands to counter the globalpandemic [14].

For that reason, the Task Force of Mask Supply Stabilization Measures was established on26 February 2020 with the Ministry of Economy and Finance. The Task Force determined specificfair distribution and supply expansion measures, in order to address the difficulties of supply of rawmaterials appealed by manufacturers. This was also done while balancing demand and supply bysimultaneously promoting cooperation and collaboration, and controlling mask demand in the market,from 6 March 2020 onwards.

To develop an appropriate resilience strategy, the magnitude and duration of the surge should beevaluated and determined to effectively respond to the disruption. However, the novel coronavirusis new to the world. Thus, organizational learning is central to managing the learning requirementto fight against the tricky and smart invisible enemy in interconnected dynamic systems [15]. Thisstudy extends the concept of organizational learning to societal learning—utilizing a system of amulti-organizational approach. The organizational learning is the collective learning to increasecapacity, create new knowledge, advance technologies, and innovative process, and respond tounexpected market changes and demand.

This study investigates the dynamic response system of Korea to the COVID-19 pandemic anddiscusses lessons learned as part of a societal learning. It is too early to say whether the response iscomplete or successful, because the system is still evolving and adapting to address the dynamic natureof outbreaks globally. Therefore, the dynamic system response approach needs flexible systems withnational and global collaboration and cooperation [13]. This study will be beneficial to the societieswho experience similar cases of a dearth of healthcare and medical masks for now and for the future.

To investigate Korea’s dynamic response systems, this study adopts an exploratory and anecdotalanalysis. In Section 2, types of masks are classified, and mask demand is analyzed regarding threescenarios, including lockdown and open democratic approaches. Demand management is alsodiscussed while considering a rotation system to deal with the shortage of masks in the market andmaintain a healthy society. Section 3 examines the ways to increase production capacity, design asupply chain network, and maintain resources of staff, finance, facility, as well as, governance andregulation. Section 4 discusses a production strategy to prepare for unexpected events in the future.Then finally, Section 5 concludes the study with a discussion of lessons learned from Korea’s dynamicresponse systems, and states the contribution of the study to the literature and the body of knowledge.

2. Product and Demand

2.1. Types of Products

Three categories are known in the face mask market in Korea. It is divided into ’industrialproducts’, ’non-drug, medical products’, and ’personal products’ (Table 1). Industrial products includerespirators that protect wearers from airborne particles, such as dust. Non-drug, medical products,such as medical masks, are products authorized by a health authority for treating, reducing, treating orpreventing diseases, and are subdivided into surgical, dental, veterinary, and procedure masks basedon practices. Personal products like face masks are used for personal healthcare and safety protection.

This study classifies the masks based on the applications (i.e., industrial, medical, and personalproducts) and fabric types (i.e., woven and non-woven fabric). In general, respirators, known as anindustrial product, are made of non-woven fabrics for industries such as construction and hazard areas.These masks are made of four protective layers: one carbon filter and one electrostatic melt-blownnon-woven fabric between two spun-bonded non-woven fabrics. Medical products such as surgical,

Systems 2020, 8, 18 4 of 17

dental, and procedure masks and medical respirators are designed for the medical industry. Medicalmasks are mainly used in hospitals and clinics to prevent infections caused by blood or saliva duringtreatment or surgery due to their liquid resistance. The masks are generally three layers with three-plymaterials of a melt-blown non-woven fabric between two spun-bonded non-woven fabrics. Wovenfabric is also being used for healthcare professionals.

Table 1. Classification of masks.

Applications Non-Woven Woven

Industrial products RespiratorsSingle-use, disposable respiratory

Medical productsSurgical masks/Dental masks

Veterinary masks/Procedure masksMedical respirator

Cloth surgical face masks

Personal products Healthcare masks Cloth masks

Healthcare masks are personal products used in daily life to protect respiratory organs from harmfulparticulate impurities or infectious sources due to their particle blocking performance. Sometimes,single-use, disposable respiratory and surgical masks are being used for personal healthcare; however,this study focuses on healthcare masks as a personal product to comply with commodity strategies torespond to the pandemic.

In the case of healthcare masks, the correction filter is used as the principle of applying high-pressurecurrent to non-woven fabric to make the micro-organisms static, adsorbing, and filtering fine dust.For example, KF94 healthcare masks in Korea are prevalent to keep people from virus penetration.KF94 is a Korea quality certification provided from the Ministry of Korean Food and Drug Safety(MFDS), formerly know KFDA, that verifies that the masks can block more than 94% of particles withan average size of 0.4 µm (micrometer) and is resistant to oily particles [16,17]. The diameter of a hairis about 50–70 µm on average. This function similarly to the respirators of the N95/R95 in the U.S., theKN 95 in China, and the FFP2 in the European Union (see Table 2).

Table 2. Types of certified healthcare, medical, and respiratory masks.

Type Korea China U.S.A. Europe FilterPerformance

CertificationBody MFDS KOSHA SAC NIOSH NIOSH and

FDA CENAirborneparticles

(efficiency)

Standards KFDANo. 2009-6

KMOEL—2017-64 GB2626-2006 NIOSH-42CFR84

FDA-21 CFR878.4040 and

CDC-NIOSH-42CFR84

EN149:2001

Oily particlefiltration Yes Yes No No Yes Yes No

Type 1 KF80(0.6 µm)

2nd Class(0.4 µm)

FFP1(0.3 µm) ≥80%

Type 2 KN90(0.3 µm) ≥90%

Type 3 KF94(0.4 µm)

1st Class(0.4 µm)

KN95(0.3 µm)

N95(0.3 µm)

R95(0.3 µm) Surgical N95 FFP2

(0.3 µm) ≥94–95%

Type 4 KF99(0.4 µm)

Special Class(0.4 µm)

KN99(0.3 µm)

N99(0.3 µm)

R99(0.3 µm)

FFP3(0.3 µm) ≥99%

Type 5 N100(0.3 µm)

R100(0.3 µm) ≥99.95%

Note: the Korea Ministry of Food and Drug Safety (MFDS); the Standardization Administration of China (SAC); theU.S. National Institute for Occupational Safety and Health (NIOSH); the Food and Drug Safety Administration(FDA); European Committee on Standardization (CEN), Sources: References [16,18–21].

Systems 2020, 8, 18 5 of 17

The letter of “N” in N95 stands for non-oily particles, while the nomenclature of “R” in R95 isresistant to oil particle. The standards of respirators N95 and R95 are approved and recommendedby the U.S. Occupational Safety and Health Administration (OSHA) and the National Institutefor Occupational Safety and Health (NIOSH) [22]. A surgical N95 mask consists of disposablefacepiece respirators (FFR) for filtering viral particles and fine dust. The surgical N95 is certified andrecommended by both NIOSH and the U.S. Food and Drug Administration (FDA). While surgicalmasks are not required for seal-check, the respirators are required to be sealed to prevent contamination.Since KF80, KF94, and KF99 have functions combined with the surgical masks and respirators, thisstudy will call KF80, KF94, and KF99 masks as healthcare masks afterwards to differentiate fromsurgical masks and general respirators.

The production of healthcare masks involves the raw materials of spunbond (SB) non-wovenfabric, melt-blown (MB) non-woven fabric filter, earrings or hair ties, and nose adhesionwires. Moreover, compared to other products, it goes through a production process ofcutting-folding-inspection-earring attachment-inspection-packaging.

2.2. Demand Planning and Management

Mask market size can be predicted by subtracting exports from the sum of domestic productionand imports. However, mask production data is not well published as it is perceived less in valueand importance than other personal protective equipment (PPE). International transactions of maskscan be queried through the UN Comtrade international trade statistics database. However, due to thenature of the various types of masks, various harmonized system (HS) codes can be used for referencesas follows [23]:

• HS 6307.90: Textiles, made up articles; sets; worn clothing and worn textile articles; rags (no.63)/Textiles; made up articles (including dress patterns), n.e.s. in chapter 63, n.e.s. in heading (no.6307)/non-woven disposal mask, hood mask, face mask, cotton mask, etc./Others (No. 630790)

• HS 3005.90: Wadding, gauze, bandages, and similar articles; (excluding adhesive dressings),impregnated or coated with pharmaceutical substances, packaged for retail sale

• HS 9018.90: Medical, surgical, or dental instruments and appliances; n.e.c. in heading no. 9018

HS 6307.90 is the most common for KF94/N95/KN95 types of masks. Table 3 shows the top20 countries importing masks, and its volume is reported in U.S. dollars from 2010 to 2018. The datafor 2019 is not complete yet at the moment. The United States is the leading country, followed by Japanand Germany. Korea ranked 13th in terms of import volume. The values reported in Table 3 could varyfrom Figure 1 because of the unit conversion, different sources of data, and the level of granularity inthe trade data. While Figure 1 used 12 digits of code, Table 3 queried information using six digits ofHS code. Nevertheless, the table tells us that the mask market is growing fast globally. Korea alsoimports the masks over $200 million per year in recent years.

Regardless of the global trend of mask import, the U.S. mask market is stagnant. Due to the globalshortage of respiratory masks, the U.S. CDC recommends Contingency Capacity Strategies duringexpected shortages and Crisis Strategies during known shortages [24]. When N95 mask supplies arerunning low, the following are recommended to optimize the supply of the respiratory equipment:

• Use respirators as identified by CDC as performing adequately for healthcare delivery beyond themanufacturer-designated shelf life.

• Use respirators approved under standards used in other countries that are similar to NIOSH(CDC’s National Institute of Occupational Safety and Health)-approved respirators.

• Use additional respirators identified by CDC as NOT performing adequately for healthcaredelivery beyond the manufacturer-designated shelf life [24].

Systems 2020, 8, 18 6 of 17

Table 3. Top 20 countries that imported the category of disposable masks (HS 6307.90) from 2010–2018(Unit: $million).

Countries 2010 2011 2012 2013 2014 2015 2016 2017 2018 Rank

U.S.A. 2688 2976 3164 3230 3422 3735 3879 4019 4311 34.3% 1Japan 991 1109 1171 1176 1155 1140 1140 1191 1261 10.0% 2

Germany 726 852 734 771 873 822 875 949 1,057 8.4% 3France 320 378 369 367 407 437 444 462 529 4.2% 4U.K. 279 266 259 283 352 357 351 352 384 3.1% 5

Mexico 218 256 275 318 353 281 299 357 370 2.9% 6China 228 233 222 268 279 267 262 300 343 2.7% 7

The Netherlands 174 212 193 195 237 222 239 289 328 2.6% 8Australia 153 159 183 197 218 232 240 269 292 2.3% 9Canada 211 225 246 260 275 254 247 256 263 2.1% 10Poland 183 172 198 244 282 286 340 277 260 2.1% 11

Italy 210 239 205 224 240 214 212 223 247 2.0% 12

Korea 73 113 112 125 140 162 156 183 234 1.9% 13

Spain 208 200 123 115 142 161 154 178 201 1.6% 14Belgium 133 151 134 142 148 136 154 159 174 1.4% 15

Switzerland 116 128 122 129 155 142 151 155 166 1.3% 16Russian Federation 84 119 149 155 147 90 133 112 132 1.0% 17

Austria 75 92 88 101 112 101 108 114 129 1.0% 18Sweden 88 104 101 105 113 108 96 107 122 1.0% 19Czechia 66 94 94 85 103 95 99 114 122 1.0% 20Others 1004 1129 1204 1305 1441 1411 1465 1558 1658 13.2%

World Total 8229 9208 9344 9795 10,594 10,653 11,043 11,621 12,586 100%

Note: The countries were ranked based on the 2018′s value ($million). Source of Data: UN Comtrade, theDepartment of Economic and Social Affairs/United Nations Statistics Division (DESA/UNSD) [23].

Given the lockdown and travel ban approach carried out in many countries, the estimates ofdemand for healthcare KF-masks in Korea are shown in Figure 2 with the area graphs of demand ofmasks and a stacked bar chart of mask supply until August of 2020. Scenario A presents a lockdownapproach with the travel ban, while Scenarios B and C demonstrate an open democratic approach.Scenario B is forecasted with very strong social distancing and minimal economic and social activitieswith limited travels. Scenario C assumes regular daily life as it was. However, if the governmentsustains an open democratic society and responds to dynamic emergency situations with uncertainty,the country needs over 200 million masks a week, resulting in demand volume for masks 1.5 timesmore than Scenario B and four times more than Scenario A.

• Basic assumptions: This study assumes that around 36.8 million masks are estimated for collegestudents, K-12 and kindergarten students, and business population in a day for five days a week.In addition, a medical population of 608,000 requires an average of 1.5 masks per day for sevendays [25].

• Scenario A: With a lockdown approach, it is assumed that strong social distancing limits socialactivities, and that only 20% of the estimated population does basic economic activities five daysa week.

• Scenario B: While maintaining strict social distancing and a high level of hygiene management,50% of the estimated population actively engage in social and economic activities for five daysa week.

• Scenario C: While practicing social distancing and a high level of hygiene management, 80% ofthe population is engaged in daily social and economic activities five days a week.

The normal demand for healthcare masks before COVID-19 was based on the needs of protectionfrom the particle matters, including industrial fine and ultrafine dust and naturally originated yellowdust from the dessert of Mongolia and northern China. Most of the demand was met by the supplyfrom China until January. Once the first coronavirus patient was reported on 20 January 2020, the

Systems 2020, 8, 18 7 of 17

demand for healthcare masks sharply increased. Since 12 February 2020, the Mask StabilizationMeasures has been effective, resulting in double the production capacity. The 31st patient became asuper-agent on 17 February 2020, resulting in a surge of mask demand. Even though the nationalcapacity increased, the shortfall of demand for Scenarios B and C was not met without importingmasks from other international suppliers or lowering the demand.

Systems 2020, 8, x; doi: FOR PEER REVIEW www.mdpi.com/journal/systems

Figure 2. Timeline of Response of Production System to COVID-19 in Korea. Until February of 2020,

the inventory was not reported by the categories of surgical masks and respirators separately.

Actors Import

(raw material)

65.3% Pharmaceutical

Distributors 0.6% Post Offices Domestic (Public Mask)

Producers (159) 80%

1.1% Marts

Domestic

Production

(raw material)

11.2% Korean Hospital

Association 63.6%

11.2% Pharmacies

Domestic (Others)

Hospital/healthcare

3.5% Korea Public

Procurement

Service

1.5% 0.2% 1.2%

0.6%

Schools

Public service

Disaster areas

0% (exception: allowed for humanitarian supply)*

Underprivileged

Trade Partners

20% Domestic

Finished Goods Importer 100%

Value 900-1000 KW 1100 KW 1300 KW 1500 KW

Figure 4. Actors in the value chain of mask products and value chain mapping [26]. The value is based

on the public mask measures [44]. The volume is the mean value between 17 April and 15 May 2020

[45]. (*) From 1 June 2020, 10% of health mask production is allowed to export.

Suppliers Manufacturers Wholesalers Retailers Consumers

Figure 2. Timeline of Response of Production System to COVID-19 in Korea. Until February of 2020,the inventory was not reported by the categories of surgical masks and respirators separately.

In effect on 26 February 2020, mask vendors are banned from exporting healthcare and surgicalmasks, and producers are limited to export masks less than 10% of the day’s production. Healthcareand surgical mask producers must quickly ship out more than 50% of the day’s production to publicsales outlets. As part of Mask Supply Stabilization Measures, the Korea Public Procurement Service(KPPS) contracted with the producers to purchase the public masks.

Based on the revised measures on 6 March 2020, the manufacturers are required to ship out 80%of total production via the public distributors within two days from the production date [26]. Twentypercent of this public volume is allocated for use by medical and healthcare staff and underprivilegedpeople. The masks are being distributed by the four medical associations to ensure fair distribution.The rest of the volume is available to the general public via the public mask distribution system.

On 6 March 2020, 726 million public health masks were distributed via public distribution channels.However, due to the long line to secure masks and limited supply, Korea began implementing thefive-day rotation system on 9 March which was successfully implemented in Taiwan to distributehealthcare masks to the public in February 2020 [27]. As the mask production capacity and inventoryincrease, the mask supply becomes stable, the public has been able to purchase up to three masks perweek since 27 April 2020.

To ensure that the general public purchases masks in rural, suburban, and urban areas, thegovernment signed contracts with three wholesalers for distribution, and the final goods are availableat around 23,000 local retailers [26]. To effectively control and manage the distribution system and

Systems 2020, 8, 18 8 of 17

inventory, the information portal of Health Insurance Review and Assessment Service was determinedto be used to connect the mask distributors of hospitals, pharmacies, national agricultural cooperatives(Nonghyup marts), and post offices [28].

3. Production Capacity Planning and Expansion

A system is a set of sub-systems, which are inter-related. A system is affected by internal andexternal environments. Every system has inputs and outputs to achieve its goals. The performanceof the system can be measured by the output. In order to respond to the global pandemic, the maskproduction system is a set of related components that work together in an uncontrollable environmentof uncertain demand to sustain an open democratic society in a healthy and safe way. To achievethe goal, the control tower should be able to regulate the inputs to gain the outputs by performingfunctions of supplying materials, producing high-quality products, and distributing masks to themarket in a timely and affordable way.

To meet emergency needs in a short time period, the mask production should respond to theneeds quickly. The production activity is a set of processes relying on direct input such as raw materialsand indirect inputs of capital investment in facilities and equipment and staff (human resources).For transforming inputs to outputs, technology availability, regulation, market condition, a qualitystandard is one of the essential factors affecting the process as a whole system. The outputs can bemeasured by the number of high-grade masks, unit cost, and profit of a product (Figure 3).

Systems 2020, 8, x FOR PEER REVIEW 8 of 18

To ensure that the general public purchases masks in rural, suburban, and urban areas, the government signed contracts with three wholesalers for distribution, and the final goods are available at around 23,000 local retailers [26]. To effectively control and manage the distribution system and inventory, the information portal of Health Insurance Review and Assessment Service was determined to be used to connect the mask distributors of hospitals, pharmacies, national agricultural cooperatives (Nonghyup marts), and post offices [28].

3. Production Capacity Planning and Expansion

A system is a set of sub-systems, which are inter-related. A system is affected by internal and external environments. Every system has inputs and outputs to achieve its goals. The performance of the system can be measured by the output. In order to respond to the global pandemic, the mask production system is a set of related components that work together in an uncontrollable environment of uncertain demand to sustain an open democratic society in a healthy and safe way. To achieve the goal, the control tower should be able to regulate the inputs to gain the outputs by performing functions of supplying materials, producing high-quality products, and distributing masks to the market in a timely and affordable way.

To meet emergency needs in a short time period, the mask production should respond to the needs quickly. The production activity is a set of processes relying on direct input such as raw materials and indirect inputs of capital investment in facilities and equipment and staff (human resources). For transforming inputs to outputs, technology availability, regulation, market condition, a quality standard is one of the essential factors affecting the process as a whole system. The outputs can be measured by the number of high-grade masks, unit cost, and profit of a product (Figure 3).

Figure 3. Generalized process diagram of medical mask production.

3.1. Global Production Trends

Fifty percent of the world’s production volume of about 10 million has been produced in China. Mask production volume from the five provinces of Zhejiang, Shandong, Hebei, Beijing, and Henan is 61.38% of China’s production volume [29]. To meet the dearth of masks, China has undertaken a mobilization of wartime proportions for the production of surgical masks. Since then, daily production increased sharply from about 10 million to 115 million in February of 2020.

However, according to the World Health Organization (WHO), demand for masks has increased more than 100 times due to the COVID-19 pandemic [30], and in January and February 2020, most of the world’s production was exported to China, ironically, where explosive demand was generated. Other countries (who were exporting masks to China) were unable to purchase raw materials supplied from China, eventually resulting in disrupting the global supply chain. Therefore, it has become impossible to meet the demand for mask products and to export finished goods to China. According to a model presented by the World Health Organization, 89 million masks will be needed every month in response to COVID-19 [31]. However, this number is still uncertain and not reliable for future demand.

Based on the UN Comtrade database, China led the mask related products export by over $5 billion in 2018 (Table 4). This explains more than 45% of the world export in value. Korea’s exporting activity was decreased by the increased domestic demand due to the MERS (Middle East respiratory syndrome) outbreak in 2015 and the increased frequency of severe fine dust alarms in the Korean

Process Input Output

Research and Development Regulation

Market Condition Quality Standards

Automation

Raw Materials Facilities

Equipment Staff

Masks Unit cost ($)

Profit ($) Inventory

Figure 3. Generalized process diagram of medical mask production.

3.1. Global Production Trends

Fifty percent of the world’s production volume of about 10 million has been produced in China.Mask production volume from the five provinces of Zhejiang, Shandong, Hebei, Beijing, and Henanis 61.38% of China’s production volume [29]. To meet the dearth of masks, China has undertaken amobilization of wartime proportions for the production of surgical masks. Since then, daily productionincreased sharply from about 10 million to 115 million in February of 2020.

However, according to the World Health Organization (WHO), demand for masks has increasedmore than 100 times due to the COVID-19 pandemic [30], and in January and February 2020, most ofthe world’s production was exported to China, ironically, where explosive demand was generated.Other countries (who were exporting masks to China) were unable to purchase raw materials suppliedfrom China, eventually resulting in disrupting the global supply chain. Therefore, it has becomeimpossible to meet the demand for mask products and to export finished goods to China. According toa model presented by the World Health Organization, 89 million masks will be needed every month inresponse to COVID-19 [31]. However, this number is still uncertain and not reliable for future demand.

Based on the UN Comtrade database, China led the mask related products export by over $5 billionin 2018 (Table 4). This explains more than 45% of the world export in value. Korea’s exporting activitywas decreased by the increased domestic demand due to the MERS (Middle East respiratory syndrome)outbreak in 2015 and the increased frequency of severe fine dust alarms in the Korean peninsula. Theexport market is led by China, Germany, USA, Vietnam, Mexico, and India by 71.5% of total exportin 2018.

Systems 2020, 8, 18 9 of 17

Table 4. Top 20 countries that exported the category of disposal masks (HS 6307.90) from 2010–2018(Unit: $million).

Exporter 2010 2011 2012 2013 2014 2015 2016 2017 2018 Rank

China 2940 3318 3675 4173 4605 4820 4569 4789 5304 45.3% 1Germany 474 572 557 607 748 704 720 767 862 7.4% 2

U.S.A. 516 544 576 677 689 660 661 676 678 5.8% 3Vietnam 106 162 259 339 475 554 526 484 546 4.7% 4Mexico 345 383 377 470 510 500 499 529 514 4.4% 5India 216 251 265 365 338 402 519 603 473 4.0% 6

The Netherlands 150 208 146 191 202 185 217 269 311 2.7% 7Morocco 86 137 91 136 201 218 289 255 229 2.0% 8France 185 191 179 190 201 168 177 183 229 2.0% 9Poland 115 116 106 115 126 122 141 157 227 1.9% 10

U.K. 181 156 158 184 208 187 155 156 179 1.5% 11Romania 79 87 115 134 136 123 122 142 162 1.4% 12Canada 79 87 115 134 136 123 122 142 162 1.4% 13Belgium 77 86 84 86 95 91 141 144 143 1.2% 14

Japan 103 114 99 105 99 98 113 130 138 1.2% 15Italy 88 84 76 82 78 78 106 112 115 1.0% 16

Turkey 88 84 76 82 78 78 106 112 115 1.0% 17

Korea 78 82 75 93 113 95 90 94 108 0.9% 18

Czechia 29 31 38 50 65 61 74 90 106 0.9% 19Sweden 86 95 90 104 100 92 89 103 105 0.9% 20Others 816 931 993 1064 1195 1076 1137 1213 1112 9.5%

World Total 6750 7625 8062 9277 10,298 10,345 10,485 11,049 11,713 100%

Note: The countries were ranked based on the 2018′s value ($million). Source of Data: UN Comtrade, theDepartment of Economic and Social Affairs/United Nations Statistics Division (DESA/UNSD) [23].

3.2. Dynamic Response

Until the first case of the infected by coronavirus on 20 January 2020 in Korea [32], the healthcaremasks including KF80, KF90, and KF94 were used to protect from the seasonal yellow sandand particle-laden smog, which are fine dust of PM2.5 particulate matter (a diameter less than2.5 micrometers). The demand exceeding the domestic production was filled by imported masks fromChina. After the first case of coronavirus, the KCDC recommended people wear one of KF healthcaremasks in public places or in situations where practicing social distancing is difficult.

The local production capacity cannot meet the surge of demand. Furthermore, the Chinesegovernment banned exporting medical masks and respirators produced in China on 19 February2020 until lifting the ban on 5 March 2020 [33], and the price of masks doubled in February 2020 [34].Nevertheless, the mask demand is also extremely high in China, and China plans to export masksone-on-one to each country under control along with mask-diplomacy. Thus, it is expected that it willbe difficult to expand the supply of high-grade masks in Korea. While the United States and Japanwere believed to have their own capacity to supply the masks and its raw materials by mobilizingtheir industries, Korea heavily relied on the Chinese suppliers of the mask raw materials by almost90% [35,36].

The healthcare mask producers in Korea started to produce more masks by utilizing the fullcapacity of all production lines. In addition, as 12 new manufacturers of healthcare masks have beenapproved since 4 February 2020, if the company starts production in earnest, it is expected that thecapacity of mask production will increase and contribute to supply and demand stability [37].

On 12 February 2020, the Korea Ministry of Food and Drug Safety announced Emergency Demandand Supply Stability Measures for Masks and Hand Sanitizer in response to the Price StabilizationAct (Article 2 and 6) to fill the gap of the imbalance of healthcare mask and surgical mask supplyand demand in the COVID-19 emergency situations. The act was implemented for the purposeof stipulating matters concerning the highest price designation and emergency supply adjustmentmeasures for healthcare and surgical masks and hand sanitizers (Report 2020-9 on the Ministry of Food

Systems 2020, 8, 18 10 of 17

and Drug Safety) [38]. This emergency implementation allows the director of the Ministry of Food andDrug Safety to order mask producers to expand healthcare mask production beyond a certain quantityconsidering the status of production facilities and the quantity produced in the past, if necessary, forthe supply and demand for healthcare masks. The government can provide physical, human andadministrative support manufacturing workforce, if it is deemed necessary for mask producers tofulfill the above orders. In principle, the export of masks is prohibited except for the export of masksfor humanitarian purposes until 30 April 2020 [38].

On 26 February 2020, the above measures deleted the temporary schedule (30 June 2020) specifiedby the revision and added a surgical mask to the listed items (the Ministry of Food and Drug SafetyNotice 2020-13). Manufacturers will be allowed to export up to 10% of the masks they produce each day.

On 6 March 2020, the measures for supplying public masks was revised, resulting in banning theexport of healthcare and medical masks. It was decided that up to 80% of domestic production wouldbe allocated by the government to the market [26].

3.3. Investing in Facility and Equipment

The government encouraged the manufacturers to produce more masks to fill the gap betweendemand and supply. Facilities and equipment are capital intensive inputs for the production process. Forthe producers expanding their capacity by upgrading existing equipment and installing new productionlines and purchasing equipment, the government provided financial supports and incentives [26]. Newproduction lines require capital cost and time to install. Accordingly, the government decided to useexisting production lines and equipment for short-term strategies. The maintenance and upgradingcosts are also subsidized.

3.4. Mobilizing Industry

If companies switch similar products, such as clothing and household goods, to masks and maskfilters, the companies are eligible to receive special funds, and their licensing process will be expedited.The government reserved a special fund of $3.5 million (4200 million Korean won) for procurementof a high performance packaging machine to raise the existing production capacity by 30%, which isequivalent to 700,000 high-grade healthcare masks per day.

Although mask production is less valuable than other products, other manufacturers are urgedto focus on mask production to respond to the pandemic. If these investments in production andequipment result in low demand in the future, the company will hesitate to invest, so the governmentdecided to purchase all of its excessive production for national safety stock until the production linesreturn to its original production line.

3.5. Staffing

The Korea Labor Standards Act (KLSA) stated that work hours per week should not exceed40 h a week and 8 h a day (Labor Standards Act, Article 50); however, the maximum number ofhours an employee can be extended up to is 52 h upon an agreement between the employer andemployee (Labor Standards Act, Article 53). This is effective from 1 July 2018 in workplaces with 300or more employees and 1 January 2020 in smaller workplaces with 50–300 employees [39]. Where theMinister of Employment and Labor deems that the extension of work hours may order the employer togive employees recess hours or leaves of absence, corresponding to the extended work hours (LaborStandards Act, Article 53). Referring to KLSA Article 52, the approval process of the special extensionof work hours was expedited. Workplaces with 5–50 employees will be given one more year—until1 July 2021—to conform to the law (Act No. 15513, Article 1). Workplaces with fewer than 30 employeeswill be allowed from 1 July 2021 to 31 December 2022, to have up to eight hours of special overtime ifsuch an agreement is made between the employer and employees (Labor Standards Act, No. 15513,Article 53).

Systems 2020, 8, 18 11 of 17

The government also subsidized the labor cost for overtime and weekend. The production line hasbeen running 24 h for seven days (three shifts a day) like during a war. The capacity expansion shouldreceive machinery to produce mask and raw materials and adequate staff level. Overtime working hourregulations were released, and the overtime labor cost was subsidized by the government. Referring tothe law, the overtime wages are as follows:

“An employer shall, in addition to the ordinary wages, pay employees at least 50/100 thereoffor extended work and pay employees who perform work on a holiday an amount the sameas or more than the following amounts:

1. Holiday work for up to eight hours: 50/100 of ordinary wages.2. Holiday work exceeding eight hours: 100/100 of ordinary wages.

An employer shall, in addition to the ordinary wages, pay at least 50/100 thereof to employeeswho perform night work (referring to the work performed between 10:00 p.m. and 6:00 a.m.of the next day). (Labor Standards Act, Article 56)”

Even if the overtime and weekend work of the producers is carried out, the difficulties of operationsare aggravated, due to the safety and health issues caused by the working hours of the maximumhyperactive capacity, and the burden of childcare, due to the postponement of beginning for the springsemester. Therefore, flexible working hours and additional staffing may be considered in addition tothe overtime.

The mask manufacturers will first arrange the human resource of mask producers throughemployment centers. For the mask producers that hire additional workers to expand mask productioncapacity, the government temporarily support the monthly labor costs of up to 800,000 Korean won(KW) per person to secure the necessary workforce until the end of June, which is the deadline ofpublic mask production plan [26].

3.6. Regulations

Healthcare and surgical masks were classified as a “quasi-drug”, due to the fiber products used forthe purpose of alleviating or preventing human diseases. Non-medical sanitary aids, such as a maskthat offers protection from cold weather, are classified as industrial consumer goods (PharmaceuticalAffairs Act, No. 14328, Article 2, 2 December 2016). Healthcare masks, as non-medical sanitary aids,should be sealed properly for each product and include essential information legally required tolabel and package for protecting consumers under the pharmacist’s law. Unpackaged bulk productshave no way to be checked (for example, if they are masks that cheat on the expiration date or fail tomeet the performance criteria). For faster processing and lowering the packaging cost, regulationson mask packaging may be mitigated from individual packages to an economy pack or bulk at theproduction stage. If doing so, public sales outlets designated by the government temporarily allow thesale of individual masks by unbulking a box of hundreds of masks and repackaging them. However,mitigation measures should not be compromised with product safety. The package should indicate theproduct, manufacturer or importer, quantity, serial number, and expiration date, etc. By eliminatingnon-value-added activities of repackaging and splitting bulk at distribution centers and retailers, thedistribution channels and pharmacies can improve quality and focus on customer service. The KoreaPharmaceutical Association argued that in order to ensure consumers’ right to know and secure thesafety of the public masks, one or two masks should be packed.

Under the current law, masks can only be licensed as non-medical (healthcare mask) if the dustcollection efficiency is over 94% based on a certain standard (the Ministry of Food and Drug SafetyNotice 2017-40). Pre-shipping and post-inspection are applied to relieve the burden of mask inspectionand shorten the lead time. In addition, if the government plans to change the grade of the public masksfrom KF94 to KF80, the production capacity will increase by 1.5 times and decrease the requirement ofraw materials of the mask filter fabric.

Systems 2020, 8, 18 12 of 17

3.7. Research and Development (R&D)

Research on nano filter masks, which are masks that can be washed and reused several times byreplacing disposable MB filters that lack supply and demand, is being actively carried out. However,no product has yet been officially approved by passing safety tests. According to the Ministry of Foodand Drug Safety, nanofabric should meet the criteria of the high standards. In order to manufactureand sell nanofabric for medical and health masks, the product must be approved after reviewing thesafety, effectiveness, and quality standards of the product with the guidelines of the manufacturingindustry. However, since nanofilters are new materials that are not used for medical supplies in Korea,the authorized test center need to prepare new safety and effectiveness criteria [40]. Several R&Dcenters and companies have been developing functional filter materials with a 99.9% sterilization ratein recent years using electrospun copper sulfide (CuS) nano materials that are harmless to the humanbody [41].

3.8. Cost and Profit

In the market, a KF94 mask is being sold at the range of 730 to 6900 KW in the middle of February2020 [42]. As per the Price Stabilization Act 10,623 (5/2/2011), the government may, when deemednecessary, to stabilize the people’s livelihood and the national economy, set price ceilings on particularlyimportant commodities. Price ceilings may be set for each region and for each trading stage, such asthe production stage, the wholesale stage, and the retail stage [43].

Due to the increase of the price of raw materials, especially with MB unwoven fabric, and addingincentives for quick production expansion, the unit cost of a product increased as well to 1000 KWper mask (Figure 4). The average labor cost per mask is 80 KW during the week, and 140 KW for thenight and weekend working hours. To expand the capacity, the government increased the unit priceof a mask by 50 KW for overproduction compared to the regular production capacity during a weekand all products produced during the weekend. The production cost of the public masks is around600–700 KW.

Systems 2020, 8, x; doi: FOR PEER REVIEW www.mdpi.com/journal/systems

Figure 2. Timeline of Response of Production System to COVID-19 in Korea. Until February of 2020,

the inventory was not reported by the categories of surgical masks and respirators separately.

Actors Import

(raw material)

65.3% Pharmaceutical

Distributors 0.6% Post Offices Domestic (Public Mask)

Producers (159) 80%

1.1% Marts

Domestic

Production

(raw material)

11.2% Korean Hospital

Association 63.6%

11.2% Pharmacies

Domestic (Others)

Hospital/healthcare

3.5% Korea Public

Procurement

Service

1.5% 0.2% 1.2%

0.6%

Schools

Public service

Disaster areas

0% (exception: allowed for humanitarian supply)*

Underprivileged

Trade Partners

20% Domestic

Finished Goods Importer 100%

Value 900-1000 KW 1100 KW 1300 KW 1500 KW

Figure 4. Actors in the value chain of mask products and value chain mapping [26]. The value is based

on the public mask measures [44]. The volume is the mean value between 17 April and 15 May 2020

[45]. (*) From 1 June 2020, 10% of health mask production is allowed to export.

Suppliers Manufacturers Wholesalers Retailers Consumers

Figure 4. Actors in the value chain of mask products and value chain mapping [26]. The value isbased on the public mask measures [44]. The volume is the mean value between 17 April and 15 May2020 [45]. (*) From 1 June 2020, 10% of health mask production is allowed to export.

On 6 March 2020, the government contracted with healthcare mask manufacturers for 900–1000 KWper mask, and pharmaceutical distributors supply them to the pharmacies for 1100 KW [46]. Somepharmacies pay 1300 KW for each unit to the pharmaceutical distributors. With the value-added tax(VAT) of 150 KW, the card membership fee of 30 KW, and labor cost of pharmacists, the price of amask is 1500 KW to the consumers [47]. First of all, in order to provide incentives for increased mask

Systems 2020, 8, 18 13 of 17

production, the standard purchase price will be raised by more than 100 KW, and the purchase pricewill be raised further, especially depending on weekend and night production performance [48].

4. Strategic Production Plan for Emergency

Table 5 summarizes production strategies for emergency preparedness, response, and recoveryphases. If the production level is high, and the demand becomes slow in the near future after flatteningthe pandemic curve, the inventory level will go high with high holding costs. Thus, the Koreangovernment guarantees to purchase the surplus inventory and production from the manufacturers.However, the demand level and the duration of the pandemic is unknown and cannot be predictedwith high uncertainty. Thus, once production systems are under control, and the demand is met, chasestrategy may be implemented [49]. Ontario, Canada has stockpiled around 55 million N95 face masksafter the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2002 and 2003, and 80% of themexpired in 2017 based upon the manufacturer’s determination [50]. They can be used only underspecial shortage situations such as COVID-19 based on U.S. CDC guidelines. Given this lesson, thelevel of inventory should be tracked, and a replacement plan should be included with the productionstrategy for long-term prediction.

Once the supply exceeds the demand with approaching the end of the pandemic, the productionstrategy will be switched to make-to-stock producing. The excess production will be purchased bythe government for the strategic national stockpile (SNS) in response to unpredictable public healthemergencies [51–53]. The emergency supply chain plays a critical role in the public health to assistthe control of epidemic outbreaks [54]. For long-term strategic logistics and supply chain plan andshort-term operational logistics management, the program should review the following functions:Collaborating and coordinating information sharing with private sectors, national agencies, and localgovernment, managing quality and controlling inventory, and designing supply chain network andforecasting demand [55].

Table 5. Production strategies for an emergency.

Prepare Respond and Recover

Capacity

• Assess risk and capacities• Prioritize emergency preparedness• Develop Research and Development

(R&D)

• Communication• Quick response (QR)• Just-in-time (JIT)• Mobilizing industry• Set-up specialized arrangement

Governance

• Develop national policiesand regulations

• Prepare operational readiness• Develop proactive partnership

• Coordinate multi-sectors and stakeholders• Secure political commitment• Cooperate and collaborate between health

and other sectors• Implement an action• Oversee and monitor progress

Resources

• Identify essential supplies• Develop contingency resources plan• Design logistics and supply

chain network• Dedicate, train, and equip

human resources

• Prioritize financial and human resources• Reinforce quality assurance and quality

control (QA/QC) procedures• Implementation of a dynamic model to

collect real-time data• Flexible use of resources

InventoryManagement

• Build stockpile• Maintain inventory level and quality

• Producing high-quality products in time• Outsourcing reliable partners• Importing from diverse channels

Source: References [13,56,57].

Systems 2020, 8, 18 14 of 17

In short, the strategic objectives should achieve a resilient system with the flexibility,whole-of-government, whole-of-society, approach, and operational readiness [13]. The strategicapproaches can be accomplished using a plan-do-check-act (PDCA) cycle. The cycle requires to planoperational readiness with stakeholder at regional, national, and international level, successfullyimplement (do) timely, cost-effective action plan by coordinating stakeholders and multi-sectors,evaluating and taking corrective action by monitoring and evaluating in line with standardizedperformance measures, tools, and process based on social and/or organizational agreement, and takeaction based on the lessons learned from the previous steps. This cycle will be reciprocal to improvethe response systems in response to dynamic environments and changes of demand.

5. Conclusions

This study investigated how Korea responded to the challenging expansion of facemask production.This is terms of dealing with the high public demand and high-quality standards to meet the suddenincrease of demand during the COVID-19 pandemic. The case study was conducted using an anecdotalanalysis and exploratory analysis with publicly available data.

The study found that transparency, openness, and cooperation are essential to get through thesechallenging times. Because the global supply chain system is critical for prosperity, and supply chainsystems all rely on each other, collaboration is essential to overcome global health crises together inopen democratic systems [13]. Since the coronavirus evolves and the spread of the virus is dynamic,borderless, and can be very rapid; the pandemic production systems needs an all-inclusive approachto management systems to meet the shortfall of PPE, including mask needs [14]. Due to the noveltyof COVID-19, the world is still learning. Thus, system thinking is crucial to public health disastermanagement for adaptation and learning [15], thereby allowing the world to respond to the virus in amanner that is timely, effective, and efficient [13].

This study contributes to the existing literature and body of knowledge by providing lessonsfrom the case of Korea’s dynamic response systems of mask production. This study also providesa systemic view of a critical piece of PPE—both for health staff and the public—to help prevent thespread of COVID-19. This study can serve as a benchmark for dynamic and timely response to theglobal pandemic and health issues.

In conclusion, the authors recommend the following:

• To develop a dynamic and timely response system to the changing market with flexible andagile operations.

• To increase visibility of inventory, distribution, and production systems.• To collaborate with public and private sectors along with global organizations (such as WHO) for

the global supply chain to overcome global challenges.• To secure multiple separate channels for healthcare staff, public service providers, the

underprivileged, and general consumers.• To increase awareness of smart consumption with effective demand management.• To develop management systems that respond to the dynamic, uncertain situations.• To develop a strategic plan for long-term, and efficient operations for short-term.

The study was limited by the shortfall of collected data, since the period of study was shortlyafter the outbreak. The mask production data is also limited because the product has been managedas several categories of general masks, medical masks, and industrial respirators. PPE, such ashealthcare masks, is essential to the outbreaks; therefore, masks should be maintained and controlledin effective ways.

Author Contributions: Conceptualization, E.L. and Y.-Y.C.; investigation, E.L., Y.-Y.C. and M.M.; resources,Y.-Y.C., M.M. and E.O.; data curation, E.L. and Y.-Y.C.; writing—original draft preparation, E.L. and Y.-Y.C.;writing—review and editing, M.M. and E.O.; visualization, E.L.; project administration, E.L. All authors have readand agreed to the published version of the manuscript.

Systems 2020, 8, 18 15 of 17

Funding: This research received no external funding.

Acknowledgments: The authors would like to thank the reviewers for valuable comments. The authors alsowould like to thank Hoobum Yoon, a student research assistant, for collecting data of public mask productionin Korea.

Conflicts of Interest: The authors declare no conflict of interest.

References

1. World Health Organization. Novel Coronavirus—Republic of Korea (ex-China). Available online: https://www.who.int/csr/don/21-january-2020-novel-coronavirus-republic-of-korea-ex-china/en/ (accessed on21 January 2020).

2. KTV. South Korean Government Joint-Briefing on COVID-19; Korea TV: Daejeon, Korea, 9 March 2020. Availableonline: http://www.ktv.go.kr/content/view?content_id=594852 (accessed on 18 April 2020).

3. Nohria, N. What Organizations Need to Survive a Pandemic; Harvard Business Review: Boston, MA, USA, 2020;Volume 30.

4. Mubareka, S.; Lowen, A.C.; Steel, J.; Coates, A.L.; García-Sastre, A.; Palese, P. Transmission of Influenza Virusvia Aerosols and Fomites in the Guinea Pig Model. J. Infect. Dis. 2009, 199, 858–865. [CrossRef] [PubMed]

5. Christian, M.D.; Loutfy, M.; McDonald, L.C.; Martinez, K.F.; Ofner, M.; Wong, T.; Wallington, T.; Gold, W.L.;Mederski, B.; Green, K.; et al. Possible SARS Coronavirus Transmission during CardiopulmonaryResuscitation. Emerg. Infect. Dis. 2004, 10, 287–293. [CrossRef] [PubMed]

6. Harvard Medical School, Coronavirus Resource Center. 2020. Available online: https://www.health.harvard.edu/diseases-and-conditions/coronavirus-resource-center (accessed on 14 April 2020).

7. Guzman, J. WHO: No Evidence Wearing a Mask Can Protect Healthy People from Coronavirus.Available online: https://thehill.com/changing-america/well-being/prevention-cures/491725-who-no-evidence-wearing-a-mask-can-protect (accessed on 25 April 2020).

8. World Health Organization. Advice on the Use of Masks the Community, during Home Care and inHealth Care Settings in the Context of the Novel Coronavirus (2019-nCoV) Outbreak. Available online:https://www.who.int/docs/default-source/documents/advice-on-the-use-of-masks-2019-ncov.pdf (accessedon 29 January 2020).

9. U.S. Center for Disease Control and Prevention. Recommendation Regarding the Use of Cloth FaceCoverings, Especially in Areas of Significant Community-Based Transmission. Available online: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html (accessed on 3 April 2020).

10. World Health Organization. Advice on the Use of Masks in the Context of COVID-19. Availableonline: https://apps.who.int/iris/bitstream/handle/10665/331693/WHO-2019-nCov-IPC_Masks-2020.3-eng.pdf?sequence=1&isAllowed=y (accessed on 6 April 2020).

11. Korea Customs Service. Trade Statistics. Available online: https://unipass.customs.go.kr/ets/index_eng.do(accessed on 13 May 2020).

12. Bank of Korea. Economic Statistics System. Available online: https://ecos.bok.or.kr/flex/EasySearch.jsp(accessed on 13 May 2020).

13. World Health Organization. A Strategic Framework for Emergency Preparedness; World Health Organization:Geneva, Switzerland, 2017.

14. Madni, A.M.; Erwin, D.; Sievers, M. Constructing Models for Systems Resilience: Challenges, Concepts, andFormal Methods. Systems 2020, 8, 3. [CrossRef]

15. Ratnapalan, S.; Uleryk, E. Organizational Learning in Health Care Organization. Systems 2014, 2, 24–33.[CrossRef]

16. Ham, S.; Choi, W.-J.; Lee, W.; Kang, S.-K. Characteristics of Health Masks Certified by the Ministry of Foodand Drug Safety. J. Environ. Health Sci. 2019, 45, 134–141. [CrossRef]

17. Kyung, S.Y.; Jeong, S.H. Particulate-Matter Related Respiratory Diseases. Tuberc. Respir. Dis. 2020, 83,116–121. [CrossRef]

18. U.S. Center for Disease Control and Prevention. NIOSH-Approved Particulate Filtering Facepiece Respirators.2020. Available online: https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html (accessedon 16 April 2020).

Systems 2020, 8, 18 16 of 17

19. Dato, V.M.; Hostler, D.; Hahn, M.E. Simple Respiratory Mask. Emerg. Infect. Dis. 2006, 12, 1033–1034.[CrossRef] [PubMed]

20. Jung, H.; Kim, J.; Lee, S.; Lee, J.; Kim, J.; Tsai, P.; Yoon, C. Comparison of Filtration Efficiency and PressureDrop in Anti-Yellow Sand Masks, Quarantine Masks, Medical Masks, General Masks, and Handkerchiefs.Aerosol Air Q. Res. 2004, 14, 991–1002. [CrossRef]

21. European Committee on Standardization, Making Standards for Europe, 6 May 2009.Available online: https://standards.cen.eu/dyn/www/f?p=204:110:0::::FSP_PROJECT:32928&cs=1B0AB06FEB70E43960D46D1198C37CC09 (accessed on 15 April 2020).

22. U.S. Food and Drug Administration. N95 Respirators and Surgical Masks (Face Masks).Available online: https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks#s6 (accessed on 20 April 2020).

23. UN Comtrade. “UN Comtrade,” United Nations Commodity Trade Statistics Database. 2019. Availableonline: https://comtrade.un.org/db/default.aspx (accessed on 14 May 2020).

24. U.S. Center for Disease Control and Prevention. Summary for Healthcare Facilities: Strategies for Optimizingthe Supply of N95 Respirators during the COVID-19 Response. Available online: https://www.cdc.gov/

coronavirus/2019-ncov/hcp/checklist-n95-strategy.html (accessed on 6 April 2020).25. KOSIS. Summary of Industry and City & Province. Available online: http://kosis.kr/statHtml/statHtml.

do?orgId=101&tblId=DT_1KB9001&vw_cd=MT_ZTITLE&list_id=J_20_6&seqNo=&lang_mode=ko&language=kor&obj_var_id=&itm_id=&conn_path=MT_ZTITLE (accessed on 27 March 2020).

26. Korea Ministry of Economy and Finance. Mask Supply and Demand Stabilization Measures. Availableonline: http://www.moef.go.kr/com/synap/synapView.do;jsessionid=7kkTyiOn4kjlqZZHDh1ckLY4.node10?atchFileId=ATCH_000000000013363&fileSn=3 (accessed on 5 March 2020).

27. Chuan, K.; Kao, E. Taiwan Approves New Rationing System for Surgical Masks. Available online: https://focustaiwan.tw/society/202002030019 (accessed on 3 February 2020).

28. Health Insurance and Review Assessment Service. “HIRA System,” May 2020. Available online: https://www.hira.or.kr/eng/about/08/02/index.html (accessed on 14 May 2020).

29. Bradsher, K.; Alderman, L. The World Needs Masks. China Makes Them, but Has Been Hoarding Them, TheNew York Times. Available online: https://www.nytimes.com/2020/03/13/business/masks-china-coronavirus.html (accessed on 13 March 2020).

30. Zhang, L. Coronavirus: Demand for Face Masks Creates Shortfall for Those in Real Need, 7 February 2020.Available online: https://news.un.org/en/story/2020/02/1056942 (accessed on 12 April 2020).

31. World Health Organization. Shortage of Personal Protective Equipment Endangering Health WorkersWorldwide, 3 March 2020. Available online: https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide (accessed on 12 April 2020).

32. Song, J.-Y.; Yun, J.-G.; Noh, J.-Y.; Cheong, H.-J.; Kim, W.-J. Covid-19 in South Korea—Challenges of SubclinicalManifestations. N. Engl. J. Med. 2020. [CrossRef] [PubMed]

33. Villasanta, A. China Hoards PPEs, Blocks Export of Coronavirus Masks: This Is ‘Considered First-DegreeMurder’. Available online: https://www.ibtimes.com/china-hoards-ppes-blocks-export-coronavirus-masks-considered-first-degree-murder-2953130 (accessed on 15 April 2020).

34. Kwai, I. How a Pharmacy Handles Mask Hoarders and Coronavirus Fears. Available online:https://www.nytimes.com/2020/02/18/world/asia/mask-hoarders-coronavirus-pharmacy.html (accessed on18 February 2020).

35. Kang, S.-Y. China Expands Mask Production and Exports, but...It’s Hard to Meet the Demand in Korea.Available online: http://www.newspim.com/news/view/20200303000784 (accessed on 3 March 2020).

36. Jin, Y.Z. Responding to the Global “Mask Shortage”: China, the United States and Japan have Made aBig Hit on Their Capacity. Available online: https://finance.sina.com.cn/chanjing/cyxw/2020-03-03/doc-iimxxstf5939393.shtml (accessed on 3 March 2020).

37. Korea Foods and Drug Administration. Announcement of the Current Status of Health Mask Production.Available online: https://www.mfds.go.kr/brd/m_99/view.do?seq=43965&srchFr=&srchTo=&srchWord=

&srchTp=&itm_seq_1=0&itm_seq_2=0&multi_itm_seq=0&company_cd=&company_nm=&page=1(accessed on 18 February 2020).

Systems 2020, 8, 18 17 of 17

38. Korea Law Information Center. Emergency Demand and Supply Stabilization Measures of Mask and HandSanitizer. Available online: http://www.law.go.kr/admRulSc.do?tabMenuId=tab133&eventGubun=060103&query=%EB%A7%88%EC%8A%A4%ED%81%AC+%EB%B0%8F+%EC%86%90%EC%86%8C%EB%8F%85%EC%A0%9C+%EA%B8%B4%EA%B8%89%EC%88%98%EA%B8%89%EC%A1%B0%EC%A0%95%EC%A1%B0%EC%B9%98#J595633 (accessed on 6 March 2020).

39. Korea Legislation Research Institute. Labor Standards Act. Available online: https://elaw.klri.re.kr/eng_service/lawView.do?hseq=50313&lang=ENG (accessed on 4 September 2019).

40. Yonhap, Scientists Develop Reusable Face Mask Filter. Available online: https://www.koreatimes.co.kr/www/nation/2020/03/119_286296.html (accessed on 17 March 2020).

41. Kwon, Y.-T.; Ryu, S.H.; Shin, J.W.; Yeo, W.-H.; Chao, Y.-H. Electrospun CuS/PVP Nanowires and SuperiorNear-Infrared Filtration Efficiency for Thermal Shielding Applications. ACS Appl. Mater. Interfaces 2019, 11,6575–6580. [CrossRef] [PubMed]

42. Oh, M.H. Mask Prices are Up to 27.2% Higher per Unit than They Were Two Weeks Ago. Available online:https://www.khanews.com/news/articleView.html?idxno=200901 (accessed on 18 February 2020).

43. Korea Law Translation Center, Korea Price Stabilization Act. Available online: https://elaw.klri.re.kr/kor_service/lawView.do?hseq=22059&lang=ENG (accessed on 27 January 2012).

44. Korea Ministry of Finance and Economy. Price Structure of Public Mask; Korea Ministry of Finance andEconomy: Seoul, Korea, 2020.

45. Korea Ministry of Food and Drug Safety. New and Notice; Korea Ministry of Food and Drug Safety: Seoul,Korea, 2020.

46. The Ministry of Economy and Finance, Price Structure of Public Mask Supply Rights. Availableonline: https://www.mfds.go.kr/brd/m_99/view.do?seq=44004&srchFr=&srchTo=&srchWord=&srchTp=

&itm_seq_1=0&itm_seq_2=0&multi_itm_seq=0&company_cd=&company_nm=&page=1# (accessed on9 March 2020).

47. Yul, L. Mask Distributors Receive 900 to 1000 Won and Supply 1100 Won to Pharmacies. Available online:https://www.yna.co.kr/view/AKR20200309001500002 (accessed on 9 March 2020).

48. Public Procurement Service, Policy Briefing. Available online: Pps.go.kr/bbs/selectBoard.do?boardSeqNo=

3060&pageIndex=1&boardId=PPS093 (accessed on 6 March 2020).49. Swamidass, P. (Ed.) Chase Strategy for Capacity Planning. In Encyclopedia of Production and Manufacturing

Management; Springer: Boston, MA, USA, 2000.50. Martell, A.; Warburton, M. Millions of Masks Stockpiled in Canada’s Ontario Expired before Coronavirus Hit;

Reuters: London, UK, 2020.51. Esbitt, D. The Strategic National Stockpile: Roles and Responsibilities of Health Care Professionals for

Receiving the Stockpile Assets. Dis. Manag. Response 2003, 1, 68–70. [CrossRef]52. Malatino, E.M. Strategic National Stockpile: Overview and Ventilator Assets. Respir. Care 2008, 53, 91–95.

[PubMed]53. Dimitrov, N.; Goll, S.; Hupert, N.; Pourbohloul, B.; Meyers, L. Optimizing Tactics for Use of the U.S. Antiviral

Strategic National Stockpile for Pandemic Influenza. PLoS ONE 2011, 6, 1–10. [CrossRef]54. Dasaklis, T.; Pappis, C.; Rachaniotis, N. Epidemics Control and Logistics Operations: A Review. Int. J.

Prod. Econ. 2012, 393–410. [CrossRef]55. U.S. Department of Health and Human Services. About the Strategic National Stockpile. Available online:

https://www.phe.gov/about/sns/Pages/about.aspx (accessed on 12 September 2019).56. Emanuel, E.J.; Persad, G.; Upshur, R.; Thome, B.; Parker, M.; Glickman, A.; Zhang, C.; Boyle, C.; Smith, M.;

Phillips, J.P. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N. Engl. J. Med. 2020, 1–9.[CrossRef]

57. National Research Council of the National Academies. Chapter 3: Emergency Management Framework;The National Academies Press: Washington, DC, USA, 2007.

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC BY) license (http://creativecommons.org/licenses/by/4.0/).